Cancer Resources > Cancer News > 2002 > April

Major surgical procedure outcomes better at high-volume hospitals

Anthony J. Brown, MD

Last Updated: 2002-04-12 9:51:58 EDT (Reuters Health)

NEW YORK (Reuters Health) - The morbidity and mortality rates of several major operations, such as pancreatic resection and radical prostatectomy, are lower at high-volume hospitals than at low-volume hospitals, according to findings from two studies published in the April 11th issue of The New England Journal of Medicine.

The current results add to a growing body of evidence that hospital volume is inversely related to the rate of adverse surgical outcomes (see Reuters Health reports October 31, 2001, December 20, 2000, and November 27, 1998).

To clarify the relationship between hospital volume and surgical mortality, Dr. John D. Birkmeyer, from the Veterans Affairs Medical Center in White River Junction, Vermont, and colleagues analyzed data from the national Medicare claims database and the all-payer 1997 Nationwide Inpatient Sample.

The analysis was limited to six different cardiovascular procedures and eight major types of cancer resection performed between 1994 and 1999. A total of 2.5 million procedures were included in the study. Hospital volume was divided into five categories: very low, low, medium, high, and very high.

For all procedures, mortality was lowest at very-high volume hospitals and highest at very-low volume hospitals. However, the absolute difference in mortality rates between these types of hospitals varied widely depending on the surgical procedure. For example, the difference in mortality rates for pancreatic resection was more than 12.5%, while the difference in such rates for carotid endarterectomy was only 0.2%.

The difference in mortality rates between very-high and very-low volume hospitals was greater than 5% for esophagectomy and pneumonectomy, 2% to 5% for gastrectomy, elective abdominal aortic aneurysm repair, and cardiac valve surgery, and less than 2% for cardiac bypass surgery, colectomy, lobectomy, and nephrectomy.

"This is the largest study to date investigating the link between hospital volume and surgical mortality," Dr. Birkmeyer told Reuters Health. "I think our study should put to rest the question of whether volume is tied to surgical risk, but the magnitude of the volume effect will probably continue to be debated."

"We were somewhat surprised at how uniform the effect of volume was across the 14 operations studied," Dr. Birkmeyer noted. "Volume mattered for all the procedures, but the extent to which it mattered varied widely depending on the operation," he added.

Dr. Colin B. Begg, from Memorial Sloan-Kettering Cancer Center in New York, and colleagues performed a similar study looking at Medicare claims records to determine the impact of hospital and surgeon volume on prostatectomy outcomes. While these volumes did not influence surgery-related death, they were inversely related to postoperative and late urinary complication rates.

In a related editorial, Dr. Arnold M. Epstein, from the Harvard School of Public Health in Boston, comments that the proportion of procedures performed at low-volume centers should probably be decreased. "Initial restrictions should be confined to metropolitan areas and focused on surgical procedures for which the differences in mortality between high-volume and low-volume hospitals are greatest."

However, efforts should also be focused on improving the quality of care at individual hospitals, Dr. Epstein emphasizes.

N Engl J Med 2002;346:1128-1144,1161-1164.

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